At graduation, some North American medical students repeat the Prayer
of Maimonides "never to forget that the patient is a fellow creature
in pain, not a mere vessel of disease."[2] How could a physician ever forget
that a patient is in pain? Don't physicians confront constant reminders­moans,
groans, winces, and other obvious manifestations of pain? Yes, but it is
those very "reminders," as I shall explain, that provoke at least
two kinds of forgetting common among physicians­one, psychological
and the other, conceptual. The psychological kind of forgetting is
primarily self-protective, but the conceptual kind has deeper roots in the
very definition of modern Medicine as curative and life-preserving. If my
analysis is right, more lecture time on pain and pain relief in medical
schools will do little to correct this "forgetting" of pain. But
there may be better remedies for pain-forgetting, some already at work in
North American medical practices.

Psychological "forgetting" of pain

Physicians and nurses have various familiar ways to forestall or discount
patients' pain reports and requests for more pain relief. In advance of
a painful procedure, they minimize the pain that a patient may experience.
('This may sting a bit,' 'You may have some headache for a short time after
the lumbar puncture.') Their clinical rationale is to reduce a patient's
fear and resistance, as well as the pain both may enhance. But these understatements
also teach patients the acceptable linguistic parameters for their subsequent
complaints. In general, when patients try to speak of pain, physicians and
nurses routinely translate their reports into talk of discomfort and distress
or even tenderness, the mere possibility of "distress."

Given clinicians' control of language and general authority, patients
may begin to question their own pain-reports. They may begin to wonder,
"Am I really in as much pain as I think?"­a seeming exception
to what philosophers call the "incorrigibility" of pain, that
is, the impossibility of being wrong about the existence or severity of
one's own pain.

Whatever the effects of clinician understatement on patients, this linguistic
discounting helps clinicians forget how much or how often their patients
are suffering, and thereby it helps clinicians distance themselves from
the pain they continually encounter and often produce in the course of diagnosis
and therapy.[3]
For such self-protective distancing to succeed, however, there must be clinical
rationales that disguise this function­and they abound. Most common
are such routine saws as i) Patients with a history of drug abuse are exaggerating
their pain in the hope of getting enough drugs for a hospital high; ii)
Patients identified by their ethnic affiliations are engaging in "typical
Italian histrionics" or "the usual Jewish kvetching;" and,
more sweepingly, iii) All patients tend to be "cry babies," regressing
toward childhood under the strain of illness and hospital routine.

Such generalizatons and stereotypes may be based on little evidence,
or none at all in the case of particular patients. But given their value
for rationalizing clinicians' self-protective underdescription of patient
pain, evidence is not at issue.

Conceptual forgetting of pain

Dismissive stereotypes and subtle self-protection aside, patient pain
is subject to a different kind of forgetting due to medical training and
professional self-definition of Modern Medicine that inspires it. From the
outset students are trained to regard pain relief as a secondary concern.
They are taught to regard pain as useful symptom for diagnosing disease
and, accordingly, to respond not by relieving but by observing and exploring
the pain, even if that involves enhancing it through palpation of soft tissues
and manipulation of joints.[4]
Hence, immediate or pain relief would be at the sacrifice of clinical information.

Likewise, students learn how helpful pain can be in following the course
of a disease, stages of healing, or the efficacy of drug therapy. More seriously,
they learn the many ways in which analgesics, especially morphine and opioids,
complicate therapeutic protocols. In addition to causing nausea, vomiting,
sedation, or constipation, analgesics may depress vital functions (cardiac,
respiratory, renal or hepatic) that may already be compromised by disease
or other medication. Developing tolerance only makes matters worse, as increasing
doses are needed to achieve the same level of relief, with increasing risk
of physiological and psychological dependencies. Critics charge that the
risk and severity of these side-effects are greatly exaggerated, in our
Puritanical, anti-drug culture. Even so, a young, cautious physician need
not be a Puritan to try to minimize these complications and risks by limiting
analgesics.

In short, from the outset physicians learn to think of pain relief as
a complication or hindrance to their diagnostic and therapeutic efforts,
not as an integral part of therapy. They early adopt the policy First
diagnose and treat; then relieve within limits.

There are, however, exceptions to this implicit policy­most notably
in the case of patients who are terminally ill or in chronic pain with no
discoverable organic causes. But these are "exceptions that prove the
rule"­the very patients of whom physicians say or think: "I'm
afraid there is nothing more we can do for you." There is, of
course, something more they could do, namely, to provide palliative
care. But, significantly, once they are certain of these diagnoses or prognoses,
physicians often relegate that task to hypnotists, acupuncturists,
biofeedback specialists, hospice nurses, or other non-physicians. The modern
physician's proper work is curing or at least arresting disease, not providing
comfort.

Not all physicians, however, transfer patients once they are judged to
be terminally ill or suffering from pain without a discoverable organic
cause. Some are willing to shift from curative efforts to pain relief, including
opioids in high and increasing dosages as needed for full relief. In so
doing, however, these physicians often provoke their colleagues' charges
that they are overdosing or, even, engaging in unprofessional conduct bordering
on homicide.

In their self-defense, physicians so charged may invoke one of several
familiar ethical principles­for example, the Principle of Double Effect
("Even if we foresee that death may result, it is relief of pain not
death that we intend"), the Principle of Patient Autonomy ("I
providing the care that my patient has competently and freely chosen"),
or the Principle of Humane Aid ("I am relieving intolerable pain").
But these replies will not persuade critics whose standards of pain relief
derive from a conception of Medicine as essentially curative and life-preserving.
For them, knowingly to cause, or even risk the death of a patient for the
sake of patient comfort is to forsake the defining goals of modern Medicine.
By so doing, physicians forfeit the right to call themselves "doctor,"
not unlike Jack Kevorkian.

I'll come back shortly to such heated claims about "the Goals of
Medicine." There is, I think, an underlying, more subtle issue, namely,
the appropriate concept of pain. What, I suggest, physicians' training
produces is a new, clinical concept of pain that tends to replace
their prior lay concept of pain. As a result, what physicians in
their training and practice come to forget is this prior, ordinary
concept that most of their patients continue to hold. As much or more than
the psychological "forgetting" of patient pain, it is this forgetting
of patients' concept of pain that sets physicians apart from their "fellow
creatures in pain." .

Concepts of pain: private, privatized, and social

To appreciate the conceptual character of this change it is necessary
first to challenge a common, but simplistic analysis of pain as solely a
private sensation. On this view, we know directly only our own pain and
must infer the pains of others from their "outward" behavior.
Accordingly, what physicians acquire is a capacity for sophisticated inferences.
From their observations and explorations, they develop a wider range data
on which to base inferences to a detailed descriptions of a patient's pain
(its location, severity, pattern), with due allowance for the ways patients
may mislead less trained inferers.

It might be said that physicians thereby have a more precise concept
of pain than the rest of us, but not a different concept. An analogy might
be the logician's more precise conception of validity, sharpened by formal
techniques for testing validity of a wider range of argument than the untrained
arguer can manage. But I think that the difference between physician and
lay concept of pain is more than degrees of precision and sophisticated
inference. And it lies not in physicians' better inferences but in their
peculiar trained responses to a patient's pain.

Normally we do not infer someone's pain from their behavior, rather,
we respond to people's pain ­ the pain manifest in their facial, vocal,
and bodily expressions.[5]
Pain is indeed a sensation but a sensation that is expressed in these various
ways, subject to our respondents. In infants, pain manifestations are initially
nonvoluntary. Crying is as natural as the suckling that relieves hunger,
and so, too, within a culture, are parental responses.[6] With time, a child's pain-manifestations
become more selective. Even before speech, infants modulate their crying,
accentuating or suppressing it in the light of the appearance or absence
of recognizable relief-givers (and pain-causers).[7] We early learn who will and will not
respond, and the circumstances in which no one will respond, and cry accordingly.
Our crying becomes largely limited to those situations in which relief is
expectable­including, of course, the relief of crying in private.

In extreme cases, suppression may become virtually total and habitual
as with the "warehoused" infants who live in cage-like cribs without
responsive attendants. Just so, patients may learn to privatize their pain­to
"suffer in silence," to "keep their complaints to themselves,"
to "put on a good face" or a "good act." This may be
prompted by clinicians' routine verbal discounting of pain-reports mentioned
above, or by their routine pseudo-inquiries, "How are we feeling today?"­a
perfunctory greeting, not a request for information. Or patients, like good
soldiers, may not want to trouble their superiors. Or they may wish to avoid
further painful investigations that honest revelation of pain would provoke.
But, clearly, even such "privatized" pain is response-relative:
patients suppress manifestations of pain in order to prevent impatient,
or dismissive, or investigative responses of their caretakers.

The techniques that researchers, as well as clinicians, use in investigating
patients' pains also reveal the public or social aspect of pain. For example,
standard lists of descriptors in pain questionnaires characterize pain as
stabbing, burning, pinching, stretching, pulling, wrenching, cutting, drilling,
gnawing, scalding, pressing, crushing. That is, we distinguish pains from
one another by way of the actions of external agents, human and otherwise,
that characteristically cause our pain. Admittedly, some descriptors are
more tied to sensation (hot, tingling, dull, throbbing, radiating, itchy),
but they a smaller fraction than we would expect if pain were conceptually
a solely private sensation.[8]

The social and public aspects of pain are also reflected in the techniques
that pain researches and clinicians use to "objectify" pediatric
pain. Children are shown a series of cartoon sketches or photographs of
children's faces ranked by the severity of the pain they supposedly represent
(the so-called "Oucher Scale"). They are asked to match their
pain to one of the faces ­an easy task for most of them. If pain is
thought of as essentially private, it is hard to see how they come to be
able to do this. Are they reading into the pictures sensations that they
have previously correlated with their own facial expressions of pain?­with
the aid of a mirror? More plausibly, they may learn the representation of
pain from the exaggerated faces that their parents and other caretakers
make in sympathetic response to their crying, grimacing, and other naturally
graded pain manifestations. Or, fascinated from an early age by other children
crying, they may learn something about pain gradations by observing caretakers'
efforts at comfort.[9]
In each of these possibilities, learning would run from public manifestations
and social responses to the "inner" sensation, not in the reverse
order as the private-sensation theory requires. In sum: pain is a public,
social, response-relative concept.[10]

If so, then in learning to substitute one kind of response for another
to patients' manifestations of pain, physicians are acquiring a different
concept of pain. In the presence of physicians who exhibit and subtly impart
their learned clinical concept of pain, some patients may themselves come
in time to take the same distanced curiosity in their pain that their physicians
show, coming to regard their own groans and winces, not as demands for immediate
relief, but as symptoms for assessment. To that extent, they will have themselves
taken on the physicians' clinical concept of pain, even in the midst of
their own pain. But the majority of patients are not so acculturated: their
expressions of pain continue in hope of sympathetic efforts at relief. Hence,
they see doctors and nurses who fail to respond appropriately, according
to this ordinary concept of pain, as insensitive or worse.[11]

Sadism and callousness

To patients who have not become medically acculturated, their physicians
and nurses may seem sadistic or callous. Freud thought that medicine attracts
people with relatively strong sadistic impulses, but not as a way of acting
on these impulses, but as a way of suppressing them through "reaction
formation." Admittedly, our advance rescue techniques (CPR, ventilators,
open heart surgery, toxic chemotherapies) may provide "undefended"
sadists with more opportunities than the physicians of Freud's day enjoyed.
And, of course, to the extent that sadism is about power over weaker, dependent
people, sadists have the simpler device of stinting on the pain-killers
they control.

For the most part, however, I think that physicians' routine practices
run counter to standard sadistic practices. As noted earlier, I take clinicians'
standard understating of patients' pain reports to be self-protection, not
against sadistic impulses but against the pain they witness or inflict in
their diagnostic and therapeutic efforts. Sadists also engage in systematic
misdescription, but in just the opposite direction: they overstate
the pain they intend to inflict or are inflicting on their masochistic partners.
Whips, chains, and studded leather hoods are ways of exaggerating in the
imagination of both sadists and masochists the amount of pain they actually
inflict and endure, respectively. This becomes necessary to avoid the serious
injury or death that they might otherwise risk.[12] Their only similarity with most doctors is their
commitment to "above all, do no harm."

Callousness is a far more serious worry. If, as I suggest, physicians
learn to forget their patients' concept of pain, they will find it easy
to ignore their patients' expectations of pain relief. What counter-measures
might be taken? Vivid films[13]
or stories[14]
about patient suffering and physician callousness may help; so, too, physician-patients
accounts of their own suffering at the hands of other physicians.[15] Another corrective
for callousness might be to require graduating medical students to spend
some time as hospital patients. Claiming to have vague symptoms, they would
at least undergo some of the painful diagnostic tests that they will routinely
impose on their own patients, as well as the hospital delays and indignities
that increase patient suffering.[16]

But if I am right about the causes of physicians' "forgetting that
their patients are fellow creatures in pain," then the underlying therapy/palliation
contrast must be challenged directly. Indeed, a variety of just such scientific
and social challenges are underway. Thanks to new guidelines,[17] large conferences, and publicity,
physicians are beginning to see how much "information" about morphine
and opioid toxicity, tolerance, addiction, and depression of vital functions
is myth.[18] Likewise,
they are learning that lower doses are needed when patients are allowed
to administer their own analgesics at will, especially before the onset
of pain. Moreover, research is beginning to show that unrelieved pain has
itself deleterious effects on vital functions, for example, on the immune
system and hence on healing.

The social challenges to the therapy/palliation contrast are even greater.
A new generation of physicians has been trained in midst of diseases for
which there have been no available cures (AIDS, Alzheimer's) or for which
therapies have proven less curative than believed (coronary artery bypasses,
some cancer chemotherapies). Hence, symptomatic relief and palliation had
to become the center of their work, not a secondary goal.

Moreover, even when there is "something more" physicians
can do to try to cure, or at least arrest a debilitating or degenerative
disease, patients or their insurers increasingly are unwilling to "fight
to the end." In such cases, palliation or "comfort care"
becomes a therapeutic option, or even "the treatment of choice"­not
an admission of clinical failure or fatigue. Relatedly, patients are asking
physicians to collaborate with non-medical (acupuncturists, hypnotists,
herbalists). Significantly, such non-medical therapies tend to be less painful
than many medical and surgical therapies. Indeed, they may work primarily
or solely by reducing the fear, anxiety, and other forms of suffering that
enhance patients' pain, whatever the cause. Moreover, these "healers"
tend to count pain-relief as a primary goal of therapy, not a secondary
concern and, so, retain (by my account) their patients' concept of pain.
Less dramatic, but with similar effect, physicians are collaborating more
with nurses and nurse-practitioners for whom pain-relief has always been
a defining goal of their profession, one that distinguishing them from doctors.
.

It remains to be seen whether these social changes, along with more precise
knowledge of pain's harms and analgesia's manageable side effects, will
give pain-relief greater status in clinical training and practice. As the
current professional debate over physician-assisted death shows, the medical
profession's self-definition as curative and life-preserving is tenacious.
But there is reason to believe that the current contrast I have drawn between
physicians' concept of pain and patients' concept of pain will shrink. If
so, then the Prayer of Maimonides may become more than ceremonial and physicians
will more easily remember that their patients are "fellow creatures
in pain, not just vessels of disease". The two forms of conceptual
and psychological forgetting would diminish, together. Were physicians to
remember their patients' concept of pain as demanding relief and act accordingly,
then, of course, they would reduce the amount of pain they would need to
"forget" by self-protective misdescription and dismissive stereotypes.[19]

Departments of Philosophy and Psychiatry, NYU

Notes

1. A revised version of a paper read
at the panel, "Mismanaging Pain," III World Congress of Bioethics,
San Francisco, California, on November 24, 1996.

2. Attributed to the 12th century
physician-philosopher Maimonides (Rabbi Moses ben Maimon, or RamBam) but
possibly of 18th century origin.

3. Other self-protective euphemisms:
surgeons "lose" patients, oncologists detect "growths,"
infants are born "with problems." Even acronyms and eponyms
may play a euphemistic role: 'ALS' and 'Lou Gehrig's disease' seem less
dire than the fully descriptive 'amyotrophic lateral sclerosis.'

4. This diagnostic response to pain
is caught by the old medical school joke:

Q. "What are the five classical signs of infection?"

A. "Rubor, calor, tumor, dolor -- and clamor." Pain (dolor)
and its expression (clamor) are assimilated to redness, heat, and swelling-all
signs or symptoms useful for diagnosis of their pathological causes.

5. Ludwig Wittgenstein:"....(Pity,
one may say, is a form of conviction that someone else is in pain.)"
Philosophical Investigations I, para.287. Readers of Wittgenstein
will appreciate that my remarks are variations on his general attack on
the view that psychological terms are to be thought of as names for private
sensations, rather than as tools whose meaning is given by uses in what
he called "forms of life," "the stream of life."

6. For us, parental comforting of
a crying baby seems as natural, or spontaneous as the crying itself. Parents,
especially mothers, who do not so respond are thought to be abnormally depressed,
exhausted, or otherwise distracted. Observers of other cultures-and honest
reporters of our "deviant" responses-show how culturally defined
the interaction of sufferer and respondent may be.

7. Wittgenstein: "A child discovers
that when he is in pain for instance, he will get treated kindly if he screams;
then he screams, so as to get treated that way. This is not pretense.
Merely one root of pretense." Last Writings, Volume I, para.867
(Blackwell 1982).

9. Is such reflexive crying an unlearned
basis or occasion for developing empathy? If so, then the movement is from
your expression of pain to my response, not from my pain through inference
to your similar sensation.

10. These public and social aspects
of the concept of pain (both lay and clinical) makes conceptual space
for the radical cultural differences that anthropologists report in manifestations
of pain (for example, in village ceremonies) and responses to pain (for
example, in maternal responses to infant whimpering in chronic food-scarce
conditions).

11. The conflict between the relief-response
concept of pain and the clinician-response concept is especially acute in
neonatal matters, partly because the relations between causes, manifestations,
and effective relief of pain are too tenuous and variable for clear definition.
Hence, the counter-charges between "heartless" surgeons and "sentimental"
lay critics. See Nancy Cunningham Butler, "Infants, pain and what
health care professionals should want to know -- an issue of epistemology
and ethics," and Dr. Neil Campbell's response in Bioethics
3:3, 1989, 181-210.

12. Indeed, even in the wild fantasies
of the Marquis de Sade (Justine) or Pauline Réage (The
Storyof O), the hapless victims who endure and then come to
enjoy the worst of imagined abuses seem to recover quickly, ready for another
orgy of whippings and penetrations.

13. For example, "Dax's Case,"
a film about a severely burned patient treated over months against his will.
During his excruciatingly painful tubbings and debridements the paramedics
keep their radio blaring. In commenting on his case, his physicians can
seem almost as unhearing. Also, The Right to Die?: The Dax Cowart Case
New York: Routledge CD ROM 1996.

14. In Ernest Hemingway's "Indian
Camp," a physician tells his young son that he does not hear the screams
of the Indian woman on whom he performs a Caesarian section without anesthesia.
Nor does he hear the empathetic cries of the woman's husband in the bunk
above her-a suicide by the end of the ordeal.

16. See the film, "The Doctor"
(dir. Randy Haines 1991) about a physician (William Hurt) who required hospitalization
as part of his medical students training after the humiliations of hospital
treatment he himself had recently suffered.

18. Cf. David Joranson, et al.
"Opioids for chronic Cancer and Non-Cancer Pain: A Survey of State
Medical Board Members. Bulletin of the Federation of State Medical Boards
of the United States, June 1992: 15-49.

19. I wish to thank Dr. Neil Campbell,
James Dwyer, F.M. Kamm, and Dr. Ronald Miller for help in clarifying these
thoughts, even though not fully sharing them.